Inspection Report Summary
The most recent inspection on November 18, 2025, found no deficiencies following a licensure resurvey and complaint investigation. Earlier inspections showed a pattern of deficiencies related primarily to resident care, including protection from abuse, dementia staff training, medication management, and safety practices such as food handling and chemical storage. Complaint investigations were mostly unsubstantiated, with the exception of a substantiated case in March 2025 involving immediate jeopardy due to failure to protect residents from abuse and elopement risks. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, correcting previously cited deficiencies in follow-up inspections.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
41 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
The visit was conducted as a Licensure Resurvey and Complaint Investigation for multiple complaint IDs at the facility.
Complaint Details
The complaint investigation involved multiple complaint IDs: KS00196539, KS00195464, KS00196604, KS00196622, KS00196914, KS00197024, and KS00197276, and was found to have no deficiencies.
Findings
The investigation and resurvey resulted in a finding of no deficiency citations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
The document represents the findings of an abbreviated investigation conducted at the assisted living facility on 04/21/25.
Findings
The abbreviated investigation resulted in no citations.
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Apr 21, 2025
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-101(f)(1), 26-41-204(i), 26-41-103(c), and 26-41-207(a)(b) were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 26-41-101(f)(1)
Deficiency related to regulation 26-41-204(i)
Deficiency related to regulation 26-41-103(c)
Deficiency related to regulation 26-41-207(a)(b)
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
An abbreviated investigation #194413 and #194283 was conducted at the assisted living facility Homestead of Crestview on 04/21/2025.
Findings
The abbreviated investigation resulted in no citations.
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 5
Date: Mar 24, 2025
Visit Reason
The inspection was a resurvey with attached complaints conducted on 03/18/25, 03/19/25, and 03/24/25 at the assisted living facility Homestead of Crestview.
Complaint Details
The resurvey included attached complaints #194043, #190751, #190622, #188798, #188113, #185378, #184221, and #178721. The complaint investigations involved allegations of abuse, neglect, and safety concerns.
Findings
The facility failed to protect residents from physical and verbal abuse, failed to keep a resident safe from elopement resulting in immediate jeopardy, failed to provide dementia training to staff upon hire, and failed to ensure safe and sanitary delivery of food items to residents' rooms.
Deficiencies (5)
Failed to protect Resident 3 from physical abuse resulting in a left eye injury of unknown origin on 03/08/25.
Failed to protect Resident 9 from verbal abuse by a direct care staff member on 01/22/24.
Failed to keep Resident 12 safe from potential injury or death due to failure to complete an accurate headcount after elopement on 09/14/24.
Failed to provide dementia training to direct care staff upon hire for five sampled staff.
Failed to ensure facility staff kept food items safe and sanitary during delivery to residents' rooms.
Report Facts
Resident census: 41
Residents in memory care unit: 12
Residents in assisted living: 29
Elopement duration: 57
Date of physical abuse incident: Mar 8, 2025
Date of verbal abuse incident: Jan 22, 2024
Date of elopement incident: Sep 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nurse Aide | Named in physical abuse finding related to Resident 3's left eye injury |
| CMA I | Certified Medication Aide | Named in verbal abuse finding related to Resident 9 |
| Administrative Staff A | Administrator/Staff | Involved in investigation and assessment of abuse incidents |
| Administrative Nurse C | Administrative Nurse | Provided statements and assessments related to abuse and elopement incidents |
| Administrative Nurse B | Administrative Nurse | Provided statements related to abuse incident investigation |
| Licensed Nurse E | Licensed Nurse | On-call nurse notified of abuse incident and involved in investigation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
The document represents the findings of a resurvey with attached complaints #194043, #190751, #190622, #188798, #188113, #185378, #184221, and #178721 at the assisted living facility conducted on 03/18/25, 03/19/25, and 03/24/25.
Complaint Details
The resurvey included attached complaints #194043, #190751, #190622, #188798, #188113, #185378, #184221, and #178721.
Findings
This plan of correction addresses the findings from the resurvey and multiple attached complaints conducted over three days in March 2025.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 14, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-10-23.
Findings
All deficiencies have been corrected as of the compliance date of 2023-11-08, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as a Re-Licensure Survey with complaint investigations for the Assisted Living Facility on 10/19/2023 and 10/23/2023.
Complaint Details
The inspection included complaint investigations with IDs 177515, 177684, 178420, 178688, 179652, and 181502.
Findings
The document represents a Plan of Correction addressing findings from the Re-Licensure Survey and multiple complaint investigations conducted during the inspection period.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 12
Date: Oct 19, 2023
Visit Reason
Re-Licensure Survey with complaint investigations for an Assisted Living Facility conducted on 10/19/2023 and 10/23/2023.
Complaint Details
The visit was a Re-Licensure Survey with complaint investigations numbered 177515, 177684, 178420, 178688, 179652, and 181502.
Findings
The survey found multiple deficiencies including inaccurate functional capacity screening, incomplete negotiated service agreements, failure to provide or coordinate necessary health care services, lack of assessment for self-administration of medication, improper documentation and storage of medications, inadequate emergency preparedness reviews, failure to post required electronic monitoring notices, and unsafe food preparation and serving temperatures.
Deficiencies (12)
Failure to ensure functional capacity screening accurately reflected resident's functional ability and need for health care services, including socially inappropriate behaviors.
Failure to ensure negotiated service agreement included description of services and provider related to inappropriate behaviors.
Failure to ensure licensed nurse provided or coordinated necessary health care services related to inappropriate behaviors.
Failure to assess resident's ability to self-administer insulin safely and correctly.
Failure to include responsible person for administration and management of selected medications in negotiated service agreement for resident self-injecting insulin.
Failure to document receipt of sample medications and include required information on medication containers.
Failure to store liquid Morphine Sulfate at room temperature as per manufacturer recommendations.
Failure to document all incidents, symptoms, and indications of illness or injury including actions taken and results.
Failure to perform quarterly reviews of the facility's emergency management plan with all residents and employees.
Failure to make weekly menu plans available to each resident.
Failure to prepare and serve food at proper temperatures, including failure to monitor food temperatures and improper handling of food trays.
Failure to post conspicuous notice at facility entrance and each resident's room regarding electronic monitoring.
Report Facts
Census: 36
Deficiencies with severity SS=D: 7
Deficiencies with severity SS=E: 1
Deficiencies with severity SS=F: 4
Medication doses: 20
Medication doses: 3
Medication doses: 10
Medication doses: 200
Medication doses: 400
Food temperature: 97
Food temperature: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Administrative Licensed Nurse | Reported on Functional Capacity Screen and Negotiated Service Agreement. |
| Certified Medication Aide I | Certified Medication Aide | Reported resident's violent tendencies and sexual behaviors. |
| Certified Medication Aide J | Certified Medication Aide | Reported resident's sexual comments. |
| Administrative Staff A | Administrative Staff | Reported expectations on FCS/NSA and emergency management plan reviews. |
| Licensed Nurse E | Administrative Licensed Nurse | Acknowledged need for service plan interventions related to inappropriate behaviors. |
| Certified Medication Aide D | Certified Medication Aide | Observed resident self-injecting insulin. |
| Certified Medication Aide F | Certified Medication Aide | Handled sample medications and food trays. |
| Dietary Staff G | Dietary Staff | Reported on food temperature monitoring and took temperature of food. |
| Certified Medication Aide H | Certified Medication Aide | Reported on food temperature monitoring on Memory Care unit. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
An offsite revisit survey was conducted on 01/23/23 for all previous deficiencies cited on 12/29/22.
Findings
All deficiencies have been corrected as of the compliance date of 01/23/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 4
Date: Dec 29, 2022
Visit Reason
The inspection was a resurvey with attached complaints to assess compliance with regulatory requirements at the assisted living facility Homestead of Crestview.
Complaint Details
The resurvey included attached complaints #176778, #176533, #171943, #171738, #164704, #161633.
Findings
The facility was found deficient in completing Functional Capacity Screens for residents following significant changes or annually, ensuring Negotiated Service Agreements fully described services residents would receive, labeling over-the-counter medications with residents' full names, and complying with tuberculosis testing guidelines for new residents.
Deficiencies (4)
Failure to complete Functional Capacity Screen for residents following significant change and annually.
Negotiated Service Agreements did not fully describe all services residents would receive.
Over-the-counter medications were not labeled with residents' full names.
Failure to comply with tuberculosis testing guidelines; missing evidence of two-step TB test for a resident.
Report Facts
Census: 38
Number of OTC medications unlabeled: 4
Days since last Functional Capacity Screen for Resident 131: 410
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed missing Functional Capacity Screen for Resident 131 and missing TB test evidence for Resident 127. |
| Administrative Nurse B | Administrative Nurse | Confirmed discrepancies in service descriptions and feeding assistance for Resident 127. |
| Certified Medication Aide B | Certified Medication Aide | Observed unlocking medication cart containing unlabeled OTC medications. |
| Certified Medication Aide C | Certified Medication Aide | Confirmed OTC medications lacked residents' names. |
| Administrative Staff E | Administrative Staff | Confirmed NSA and HCP were combined in one document. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
This document is a plan of correction submitted in response to a resurvey with attached complaints conducted on 12/28/22 and 12/29/22 at the assisted living facility.
Complaint Details
The resurvey included attached complaints #176778, #176533, #171943, #171738, #164704, and #161633.
Findings
The plan of correction addresses findings from a resurvey and multiple complaints identified during the inspection conducted on 12/28/22 and 12/29/22.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Jun 10, 2021
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
All previously cited deficiencies were corrected as of the revisit date, with corrections completed and verified for multiple regulatory items.
Deficiencies (5)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (g)(3)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-103 (c)
Deficiency related to regulation 28-39-254
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 5
Date: May 4, 2021
Visit Reason
The inspection was conducted as a resurvey and complaint investigation covering multiple complaint investigations (#149472, #152893, #154377, #154544, #154991, #155584, #156283, #159283, and #159346) over several days from 04-26-21 to 05-04-21.
Complaint Details
The inspection included complaint investigations identified by numbers #149472, #152893, #154377, #154544, #154991, #155584, #156283, #159283, and #159346 conducted over multiple days from 04-26-21 to 05-04-21.
Findings
The facility was found deficient in multiple areas including failure to ensure negotiated service agreements reflected self-administration of medications, improper labeling of over-the-counter medications, failure to date insulin pens and other medications per manufacturer guidelines, lack of dementia-specific staff training upon hire, and failure to secure hazardous chemicals to protect residents and staff.
Deficiencies (5)
Negotiated service agreement did not reflect resident self-administration of some medications and failed to identify responsible party for medication management for resident #307.
Licensed nurse or pharmacist failed to label over-the-counter medications with the resident's full name for 6 residents.
Failure to ensure licensed nurses and medication aides did not administer medications beyond the manufacturer's or pharmacy provider's recommended expiration date, including insulin pens and tuberculosis testing solution.
Failure to provide staff orientation and in-service education on treatment and appropriate response to behaviors associated with dementia for new hires.
Facility failed to ensure it was equipped and maintained to protect health and safety regarding unlocked hazardous chemicals accessible to residents and staff.
Report Facts
Resident census: 28
Residents managed medications: 26
Residents with insulin injections: 2
Residents on special care dementia unit: 6
Direct care staff hired since last dementia training: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Licensed Nurse | Provided resident roster, confirmed medication administration practices, and acknowledged lack of dementia training and chemical safety issues. |
| Licensed nurse D | Licensed Nurse | Completed self-medication assessments and identified deficiencies in negotiated service agreements. |
| Administrator E | Administrator | Provided personnel lists, acknowledged lack of dementia training upon hire, and addressed chemical safety concerns. |
| Certified Medication Aide A | Certified Medication Aide | Observed medication carts and labeling practices, confirmed medication handling procedures. |
| Certified Medication Aide B | Certified Medication Aide | Observed medication carts, insulin pen handling, and labeling practices. |
| Direct Care Staff G | Direct Care Staff | Reported lack of dementia training at hire and described resident behaviors. |
| Direct Care Staff H | Direct Care Staff | Reported lack of dementia training at hire and described resident behaviors. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Oct 3, 2019
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date.
Deficiencies (5)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-104 (a)
Deficiency related to regulation 26-41-206 (d)
Deficiency related to regulation 28-39-254
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 5
Date: Aug 14, 2019
Visit Reason
The inspection was conducted as a licensure resurvey and complaint investigations for complaints #140287, #141475, and #143423 at an assisted living facility.
Complaint Details
The visit was triggered by complaints #140287, #141475, and #143423 as part of a licensure resurvey.
Findings
The facility was found deficient in multiple areas including improper labeling of over-the-counter medications, lack of verification of staff licensure and registry, failure to conduct adequate emergency evacuation drills, unsafe food preparation and storage practices, and unsecured hazardous chemicals posing risks to cognitively impaired residents.
Deficiencies (5)
Failure to ensure licensed nurse or pharmacist labeled over-the-counter medications with resident's full name for 3 residents.
Failure to have evidence of verifying nursing license and nurse aide registry for certain staff members.
Failure to conduct emergency evacuation drill with sufficient staff to assist residents requiring help to a secure location.
Failure to ensure food was stored and prepared under safe and sanitary conditions including proper sealing, dating, temperature monitoring, hairnet use, and kitchen cleanliness.
Failure to secure all chemicals to maintain safety of cognitively impaired residents; unlocked cabinets contained hazardous cleaning chemicals.
Report Facts
Census: 24
Residents with cognitive impairment: 8
Residents with medications managed: 23
Deficiencies cited: 5
Evacuation drill duration: 4
Resident head count during drill: 253
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse D | Licensed Nurse | Observed medication cart and OTC medication labeling practices. |
| certified medication aide C | Certified Medication Aide | Observed medication cart and OTC medication labeling practices; observed dishing dessert with improper hairnet use. |
| licensed nurse/operator E | Licensed Nurse/Operator | Confirmed lack of license verification, nurse aide registry checks, and deficiencies in emergency evacuation drill and kitchen conditions. |
| dietary staff G | Dietary Staff | Observed food storage and preparation deficiencies including undated food and kitchen cleanliness. |
| maintenance staff F | Maintenance Staff | Conducted fire drill and provided documentation of evacuation drill. |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Sep 11, 2018
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously identified deficiencies under regulations 26-41-202(i), 26-41-204(g)(h), and 26-41-205(g)(4) have been corrected as of 09/11/2018.
Deficiencies (3)
Deficiency under regulation 26-41-202(i) corrected
Deficiency under regulation 26-41-204(g)(h) corrected
Deficiency under regulation 26-41-205(g)(4) corrected
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 3
Date: Aug 16, 2018
Visit Reason
The inspection was a resurvey with investigation of complaints #121569, #126491, and #131330 at the assisted living facility on 8/13/18, 8/14/18, and 8/16/18.
Complaint Details
The visit was complaint-driven based on complaints #121569, #126491, and #131330. The findings substantiated failures in service provision and documentation related to negotiated service agreements, skilled nursing care, and medication management.
Findings
The facility failed to ensure residents received services according to their negotiated service agreements, including housekeeping and laundry services. The licensed nurse did not document skilled nursing services such as insulin injections or the receipt and administration of sample medications according to policy. The facility lacked a policy for sample medications and failed to follow procedures for documenting and informing residents about sample medications.
Deficiencies (3)
Failed to ensure each resident received services according to their negotiated service agreement, including housekeeping and laundry services.
Failed to ensure licensed nurse documented skilled nursing care, including insulin injections and outcomes, in the resident's record.
Failed to follow policies and procedures for receipt, documentation, and administration of sample medications, including lack of documentation and resident notification.
Report Facts
Census: 19
Sample residents reviewed: 3
Focus review residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Licensed Nurse | Named in findings related to scheduling, documentation failures for insulin injections, and sample medication management. |
| Certified staff G | Certified Staff | Named in findings related to housekeeping duties and staffing changes. |
| Licensed nurse E | Licensed Nurse | Mentioned in relation to sample medication policy and procedure. |
| Certified medication aide D | Certified Medication Aide | Observed handling sample medication without proper documentation. |
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 29, 2016
Visit Reason
The licensure resurvey with investigation of complaint #105188 of the assisted living facility was conducted on 12/28/16 and 12/29/16.
Complaint Details
Complaint #105188 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The investigation and licensure resurvey resulted in no deficiency citations being found.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 15, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 26-41-207 (a) (b) with ID prefix S3305 was corrected as of 06/15/2015.
Deficiencies (1)
Deficiency related to regulation 26-41-207 (a) (b)
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: May 14, 2015
Visit Reason
The inspection was a resurvey with complaints #81431 and #CSGS11 conducted on 5-7-15, 5-12-15, 5-13-15, and 5-14-15 to investigate issues related to health care services, infection control, and facility safety.
Complaint Details
The visit was complaint-related, investigating complaints #81431 and #CSGS11. The complaints involved failure to provide adequate health care services to residents with cognitive impairments and multiple falls, inadequate infection control practices related to Clostridium difficile, and unsafe storage of chemicals.
Findings
The facility failed to ensure licensed nurses provided or coordinated necessary health care services for cognitively impaired residents who experienced multiple falls. Infection control policies and procedures were inadequate for managing a resident with Clostridium difficile, including lack of staff education and personal protective equipment availability. Additionally, the facility failed to secure chemicals, posing a safety risk to cognitively impaired residents.
Deficiencies (3)
Failed to ensure licensed nurse provided or coordinated necessary health care services for cognitively impaired residents who experienced multiple falls.
Failed to ensure provision of a safe, sanitary, and comfortable environment by not implementing appropriate infection control policies and procedures for Clostridium difficile, including lack of staff education and PPE availability.
Failed to protect health and safety of cognitively impaired resident by not securing chemicals.
Report Facts
Resident census: 34
Number of residents sampled: 3
Number of falls for resident #100: 13
Number of positive C-diff cultures for resident #100: 6
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 16, 2014
Visit Reason
The inspection was conducted to investigate allegations of abuse, neglect, or exploitation and to assess compliance with regulatory requirements related to staff treatment of residents, functional capacity screening, negotiated service agreements, health care services, resident record documentation, and infection control policies.
Complaint Details
The visit was complaint-related, focusing on allegations of abuse, neglect, or exploitation. The report indicates failures in timely reporting, investigation, and corrective actions related to these allegations.
Findings
The facility was found to be non-compliant with multiple regulatory requirements including failure to report and investigate allegations of abuse or neglect timely, incomplete functional capacity reassessments, lack of written negotiated service agreements for residents, inadequate health care services coordination, insufficient documentation of incidents, and deficiencies in infection control policies and employee education.
Deficiencies (6)
Failure to report and investigate allegations of abuse, neglect, or exploitation within required timeframes.
Failure to conduct functional capacity screening reassessments at required intervals.
Failure to develop written negotiated service agreements for each resident based on functional capacity screening and service needs.
Failure to provide or coordinate health care services as required, including personal care and supervised nursing care.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
Failure to prohibit employees with communicable diseases or infected skin lesions from contact with residents or resident care equipment and failure to provide required infection control education and tuberculosis guideline compliance.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Oct 16, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies were corrected by the specified dates in October 2014.
Deficiencies (6)
Deficiency related to regulation 26-41-204 (e)
Deficiency related to regulation 26-41-205 (d) (4)
Deficiency related to regulation 26-41-205 (a) (3)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-205 (i)
Deficiency related to regulation 26-41-104 (a)
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 12
Date: Sep 22, 2014
Visit Reason
The inspection was a resurvey with investigation of complaints #78289 and #79265 conducted on 9/15/14, 9/16/14, 9/17/14, 9/18/14, and 9/22/14.
Complaint Details
The inspection was a resurvey with investigation of complaints #78289 and #79265 conducted on 9/15/14, 9/16/14, 9/17/14, 9/18/14, and 9/22/14. The operator failed to report and investigate a resident death incident timely and failed to document the incident properly.
Findings
The facility was found deficient in multiple areas including failure to report and investigate a resident death incident timely, failure to conduct functional capacity screenings annually, failure to develop comprehensive negotiated service agreements, improper delegation of nursing duties, improper medication storage and handling, inadequate documentation of incidents, insufficient staffing for emergency evacuations, and non-compliance with tuberculosis screening requirements for employees.
Deficiencies (12)
Failed to report to the department within 24 hours and failed to conduct an investigation when a certified staff member found resident #154 deceased on the floor.
Failed to ensure a licensed nurse conducted a functional capacity screening at least every 365 days for resident #152.
Failed to ensure the development of a written negotiated service agreement for resident #153 that described services, providers, and payment responsibilities.
Failed to ensure health care services provided or coordinated by licensed nurse included personal care by certified or licensed staff or supervised nursing care for resident #153.
Failed to appropriately delegate blood glucose testing to certified medication aides and document competency.
Failed to appropriately delegate insulin pen preparation and dose dialing to certified medication aides and document competency.
Failed to ensure licensed nurse or pharmacist placed the full name of the resident on over-the-counter medication packages or bottles.
Failed to store discontinued controlled medications in a locked compartment within a locked medication room, cabinet, or medication cart.
Failed to maintain records documenting destruction of discontinued controlled medications according to acceptable standards of practice.
Failed to ensure resident #154's record contained documentation of a certified staff member finding resident on the floor, including date, time, and action taken.
Failed to ensure sufficient staff on night shift to assist residents requiring help to evacuate to a secure location in an emergency or disaster.
Failed to ensure compliance with tuberculosis guidelines for adult care homes for employee #B, lacking symptom screen and chest x-ray within 7 days of employment.
Report Facts
Residents present: 31
Residents sampled: 4
Focus review residents: 1
Staffing pattern day shift: 3
Staffing pattern evening shift: 3
Staffing pattern night shift: 2
Discontinued controlled medications counted: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #B | Licensed Nurse | Named in multiple findings including failure to report resident death, failure to delegate nursing procedures properly, failure to document incident, and failure to comply with tuberculosis screening. |
| Certified nursing assistant #G | Certified Nursing Assistant | Found resident #154 deceased on the floor. |
| Certified medication aide #A | Certified Medication Aide | Performed blood glucose testing and insulin pen preparation without documented delegation. |
| Licensed nurse #F | Licensed Nurse | Documented resident #154's return from hospital. |
| Administrative staff #C | Administrative Staff | Did not report or investigate resident #154's death incident. |
Inspection Report
Abbreviated Survey
Census: 31
Deficiencies: 1
Date: Apr 8, 2014
Visit Reason
The inspection was an abbreviated survey conducted on April 7-8, 2014, to assess compliance with regulations related to resident admission, transfer, and discharge policies.
Findings
The facility failed to ensure that a resident was permitted to remain in the adult care home and was discharged without meeting required conditions such as the resident's welfare or safety concerns. Documentation was lacking to justify the discharge, and interventions for socially disruptive behaviors were not documented.
Deficiencies (1)
Failure to ensure that the resident was permitted to remain in the adult care home and was not discharged unless conditions were met, including lack of documentation supporting the discharge.
Report Facts
Census: 31
Closed record review: 1
30 day notice date: Feb 26, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff A | Named in progress notes related to resident behavior and hospital transfer | |
| Administrative Staff | Interviewed regarding issuance of 30 day notice and meetings with resident | |
| Operator | Signed 30 day notice and involved in discharge decision |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087059 CSGS12
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID CSGS12 for facility State ID N087059.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a record of the Plan of Correction status and related metadata.
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